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MCM mine > [CLMD] Stupor and Coma [Sachen] > Flashcards

[CLMD] Stupor and Coma [Sachen] Flashcards

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1
Q

Consciousness is defined by?

A

Total Awareness of Self and Environment

  • must be alert, and able to interact with the environment
  • must be aware (know whats going on)
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2
Q

Consciousness is arousal of the Cerebral Cortex by what?

A

Ascending Reticular Activating System

(ARAS)

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3
Q

The ARAS projects to what regions of the brain?

A

Hypothalamus

Thalamus

Cortex

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4
Q

When we talk about impaired consciousness what do we mean?

A

Diffuse or Bilateral Impairment of Both Cerebral Hemispheres

or

Failure of Brainstem ARAS

or

all of the above

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5
Q

States of Altered Consciousness

What is Confusion?

A

Attention Deficit, Orientation Disturbed, stimuli misinterpreted

(Alert, but not oriented)

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6
Q

States of Altered Consciousness

What is Delirium?

A

Disoriented, Stimuli misinterpreted, HALLUCINATIONS (visual)

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7
Q

States of Altered Consciousness

What is Stupor?

A

Pt only arouses to NOXIOUS stimuli (pinching etc), not environmental (only rudimentary awareness)

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8
Q

States of Altered Consciousness

What is Coma?

A

Not Aroused, Responsive, Aware

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9
Q

Are the states of Altered consciousness fixed states?

A

No! you pass through any/all of them on the way to or from coma.

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10
Q

When Assessing a comatose pt, what are the steps?

A

History

General Med Examination

Neuro Exam

Lab Eval

Dx/Tx

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11
Q

When taking a History, what are some examples of Sudden vs Gradual onset stupor or coma?

A

Sudden –> Vascular

Gradual –> Liver Failure/Drug Intoxication

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12
Q

What are some things to consider asking the family of a stuporess/comatose pt?

A

How and When Pt was found

Sudden or Gradual Onset

Prior Illness

Recent Symptoms (fever, confusion)

History of Substance Abuse

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13
Q

When doing a general exam on a comatose pt what are some things to consider?

A

Vitals

Skin

Breath Odor

Signs of Trauma

Neck Stiffness

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14
Q

If a patient has HTN what are some neurological considerations?

A

Pheochromocytoma,

Drugs (amphetamines, cocaine, phencyclidines)

Increased ICP

PRES

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15
Q

If a patient has hypotension what are some neurological considerations?

A

Addisons dz

Sepsis

Drugs (beta Blocker, Ca Ch Blocker, TCAs, Li, Sedatives etc)

(can lead to brain death)

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16
Q

If a patient is hyperthermic what are some neurologic considerations?

A

Infection

Heat Stroke

Drugs (Amphetamines, TCA’s, Cocaine, Salicyclates, Neuroleptics)

Serotonin Syndrome

Central Pontine Hemorrhage

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17
Q

If a patient is Hypothermic what are some neurologic considerations?

A

Hypothyroid

Hypoglycemic

Exposure

Drugs (opioids, sedatives, barbs, phenothiazine, Alcohol)

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18
Q

If a patient comes in with the following breath odors what are your considerations?

Dirty Restroom –>

Fruity –>

Musty –>

Onion –>

Garlic –>

A

Dirty Restroom –> Uremia

Fruity –> Ketoacidosis

Musty –> Hepatic Failure

Onion –> Paraldehyde (not used anymore to tx seizures)

Garlic –> Organophosphates (insecticies)

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19
Q

What are the 3 broad categories that produce coma?

A

Large, Pressure prodcing Supratentorial Mass Lesions

Infratentorial Mass Lesions (involving brainstem)

Diffuse of Multifocal Brain Disease

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20
Q

What are some causes of Supratentorial Stupor and Coma?

A
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21
Q

What are some causes of Subtentorial stupor and coma?

A

Pontine Hemorrhage

Basilar A occlusion

Central Pontine Myelinolysis

Cerebellar Hemorrhage/infarct

Cerebellar/Brainstem neoplasm

Cerebellar Abscess

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22
Q

What are some examples of Toxic Metabolic (Diffuse) Casues of stupor and coma?

A

Hypoxia

Meningitis/Encephalitis

Hypoglycemia

Hyperglycemia

Hyponatremic

Hepatic Failure

Malig. HTN

Drug Withdrawl

Seizures

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23
Q

For each of the Essential parts of the Neuro Exam what are the corresponding parts of the brainstem that you are testing?

Pupillary responses

Corneal Reflex

Extraocular Movements

Cough/Gag

Motor Responses

Respiratory Pattern

A

Pupillary responses –> Midbrain

Corneal Reflex –> Pons/Midbrain Jxn

Extraocular Movements –> Pons

Cough/Gag –> Lower Pons/Upper Medulla

Motor Responses –> All levels

Respiratory Pattern –> Cervical/Medullary Jxn

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24
Q

What are the nearly essential parts of a neuro exam?

A

Neck Stiffness

Carotid Auscultation

Fundoscopic Exam

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25
What is the step wise pattern to test the Brainstem Reflex Pathway?
1st) Pupil reflex 2nd) Corneal Reflex 3rd) Cold Water Irrigation of each eye 4th) Gag Reflex 5th) Pressure on Supraorbital N
26
For each of the following what Nerves are you testing? ## Footnote 1st) Pupil reflex 2nd) Corneal Reflex 3rd) Cold Water Irrigation of each eye [COWS pneumonic] 4th) Gag Reflex 5th) Pressure on Supraorbital N
1st) Pupil reflex --\> **2/3** 2nd) Corneal Reflex --\> **5/7** 3rd) Cold Water Irrigation of each eye --\> **3/4/6/8** 4th) Gag Reflex --\> **9/10** 5th) Pressure on Supraorbital N --\> **5/7**
27
When Evaluating the Pupillary responses what is the Sympathetic Pathway?
[1st order Neuron] Hypothalamus --\> Lower Cervical Cord --\> Symp chain [2nd order neuron] Symp Chain --\> Superior cervical ganglion [3rd Order Neuron] SCG --\> up carotid A. to CN V, Long Ciliary N --\> Muellers Muscle
28
When Evaluating the pupillary response what is the Parasympathetic pathway?
Upper midbrain (Edinger-Westfall N) --\> CN 3 --\> Ciliary Ganglion --\> Short Ciliary N (Constrictor)
29
If you find absent or unequal responses when doing the pupillary response, what does this mean?
Brainstem Lesion
30
When you are evaluating Anisocoria, how do you know which is the abnormal pupil?
It its a large pupil --\> it wont constrict to light it its a small pupil --\> it wont dilate in dark
31
What are the following locations for the common pupillary responses? Enlarged Pupil on One Side Enlarged Bl Constricted Pinpoint Midposition/Unreactive
Enlarged Pupil on One Side --\> **Parasymp Dsfxn, CN 3** Enlarged Bl --\> **B/l CN 3, PostIctal, intoxications** Constricted --\> **Symp Dsfxn (hypothalamus/carotid)** Pinpoint --\> ****_P_**ontine Lesions, O**_p_**iates, **_P_**ilocarpine** Midposition/Unreactive --\> **Symp + Parasymp (midbrain)**
32
What are the 3 P's of Pinpoint Pupils?
Pontine Lesion oPiates Pilocarpine
33
How do each of the following affect pupillary signs? Atropine/Scopalomine Opiates Pilocarpine Hyperthermia, Anoxia, Ischemia
Atropine/Scopalomine --\> **Dilated, Fixed** Opiates --\> **Pinpoint, +/- reactive** Pilocarpine --\> **Pinpoint** Hyperthermia, Anoxia, Ischemia --\> **Possibly Dilated, Fixed, Unequal (Midposition)**
34
What is the difference between Frontal vs Pontine Gaze Centers?
Frontal Gaze Centers deviate eyes to OPP side Pontine deviate eyes to SAME side
35
What do we mean when we say the following: Conjugate Roving EOM Movements Dysconjugate Roving EOM Movements
Conjugate --\> brainstem intact Dysconjugate --\> brainstem lesion
36
When we are talking about a Hemispheric Lesion what do we mean by the following? Destructive Irritative
Destructive --\> eyes go Toward lesion Irritative --\> eyes go Away from lesion
37
When we are talking about a Brainstem lesion what do we mean by a destructive lesion?
Eyes move away from lesion
38
If a patient comes in with Nystagmus and presents with any of the following. What are locations of the lesions? Ping-Pong (R-L deviation) Convergence (rapid abduction with rapid jerk back) Retractory (retraction orbit) Bobbing (rapid down, slow up) Dipping (rapid up, slow down)
Ping-Pong --\> **Bihemispheric, Midbrain** Convergence --\> **Mesencephalon** Retractory --\> **Mesencephalon** Bobbing --\> **Pons** Dipping --\> **Bihemispheric**
39
What is the Oculocephalic Maneuver (Dolls Eyes) test testing?
Testing CN 3,4,6 location is MidPons
40
What is the Caloric (oculovestibular reflex) reflex test testing?
**Lower Pons** Puts Cold water in 1 ear --\> **Eyes deviate to irrigated side if unilateral irrigation** Puts cold water in both ears --\> **eyes deviate downward**
41
What is the difference between Decorticate vs Decerebrate posturing?
Decorticate --\> Arms Flexed, Legs Extended (hemispheric) Decerebrate --\> all extremities extended (brainstem)
42
A Flaccid positioning of a comatose patient suggests what?
Pontomedullary or Metabolic causes
43
What is Cheynes-Stokes respiratory pattern?
Hyperpnia regularly alternating with apnea (b/l hemispheres or diencephalon)
44
What is Central Neurogenic Hyperventilation respiratory pattern?
**Continous hyperventilation** Midbrain
45
What is Apneustic Breathing?
**Long inspiration followed by apnea** | (mid/low pons)
46
What is Ataxic respiratory pattern?
**Completely irregular breathing** | (Medullary Respiratory Center)
47
What are the 4 main categories of causes of stupor or coma?
Supratentorial Subtentorial Diffuse/Metabolic Psychiatric
48
Progression of signs for supratentorial mass lesions usually move in what direction?
Rostral to Caudal Motor Signs are Asymmetric
49
What is usually caused by a Supratentorial Mass Lesion?
**Herniation** (the so called rostral to caudal progression of herniation)
50
What are the 3 types of Herniation syndromes seen in SupraTentorial Mass Lesions?
Uncal Transtentorial Central Transtentorial Cingulate Gyrus
51
Which type of herniation, goes under the edge of the tentorium compression CN 3, than contralateral brainstem, than respiratory abnormalities, posturing, fixed pupils, and death?
Uncal Transtentorial Herniation
52
Which herniation goes into the foramen magnum and leads to early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest, and death
Central Transtentorial Herniation
53
Which herniation goes under the falx?
Cingulate Gyrus Herniation
54
What is usually found on a Subtentorial Mass Lesion?
Preceding Brainstem Dsyfxn Sudden Onset of Coma Localizing Brainstem signs precede/accompany coma Cranial Nerve Palsies present Bizarre respiratory pattern
55
What is usually found when you have a Diffuse/metabolic cause?
Confusion and stupor common precede motor signs Motor signs are symmetrical Pupillary rxns are preserved Asterixis, Myocolonus, Tremor, Seizures Acid-base Imbalance Levels of conciousness fluctuate
56
What are some of the top causes of diffuse/metabolic?
Hepatic Failure (renal failure less common) Hyper/Hypoglycemia Hypoxia
57
What is Global Cerebral Ischemia?
When blood flow is inadequate to meet the metabolic requirements (oxygen and glucose) of the brain (like in cardiac and pulmonary arrest) ## Footnote *(causes reversible encephalopathies to brain death)*
58
What happens if someone has Breif (\< 6 mins) ischemic episode?
Reversible usually has anterograde/retrograde amnesia recovery within 7-10 days
59
What is seen with Prolonged Ischemic Episodes?
Pts comatose for atleast 12 hrs, and may have lasting focal or multifocal motor, sensory, and cognitive defects
60
What is seen in a persistent vegetative state?
Awake, but not fxnally decorticate and unaware of surroundings eye opening, eye movements, sleep wake cycles and brainstem and spinal reflexes usually intact
61
Brain death implies what?
Irreversibility Compelte Cessation of Brain fxn Persistence
62
When we talk about cessation of brain fxn what criteria does that mean?
Unresponsive to all sensory input, pain and speech Absent Brainstem Reflexes (Pupillary, Corneal, Oculocephalic, Oculovestibular, Respiratory Responses)
63
What is the Apnea Test?
To see if a patient will have respiratory movements (showing braisntem fxn) when lack of oxygen is applied.
64
What is meant by persistence factor of brain death?
Criteria for brain death (a positive apnea test) must persist for a aggreed amount of time. 6 hours with a confirmatory flat EEG 12 hrs with a confirmatory isoelectric EEG 24 hrs for an anoxic brain injury without a confirmatory isoelectric EEG
65
What are the Initial Steps of managing a Comatose Pt?
Insure open airways insure breathing and adequate oxygenation insure adequate circulation and control any active bleeding (Stabilize neck as well) Quick History GME EKG -- monitor arrythmias Give Glucose and Thiamine Give antidote (narcan ex) adjust body temp control agitation stop seizures if present
66
What are some good laboratory evaluations for a comatose pt?
Venous Blood Arterial Blood Urine culture, drug screen LP with CSF for cell count
67
What are some diagnostic tests to run on a comatose pt?
Non Contrast Head CT LP MRI EEG
68
How can you reduce elevate ICP in a comatose pt?
Elevate head of bed intubate and hyperventilate PCO2 of 20mm Mannitol./Hypertonic saline for ischemic lesions Decadron for tumor, abscess Furosemide
69
How do you treat seizures in a comatose pt?
Lorazepam Phenytoin
70
What is the Glasgow coma scale?
A scale of 3-15, measuring the "depth" of coma by the pts eye opening, verbal responses, and motor responses

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